Canadian perspectives: Update on inhibition of alk-positive tumours in advanced non-small-cell lung cancer

Abstract

Background Inhibition of the anaplastic lymphoma kinase (alk) oncogenic driver in advanced non-small-cell lung carcinoma (nsclc) improves survival. In 2015, Canadian thoracic oncology specialists published a consensus guideline about the identification and treatment of ALK-positive patients, recommending use of the alk inhibitor crizotinib in the first line. New scientific literature warrants a consensus update. Methods Clinical trials of alk inhibitor were reviewed to assess benefits, risks, and implications relative to current Canadian guidance in patients with ALK-positive nsclc. Results Randomized phase iii trials have demonstrated clinical benefit for single-agent alectinib and ceritinib used in treatment-naïve patients and as second-line therapy after crizotinib. Phase ii trials have demonstrated activity for single-agent brigatinib and lorlatinib in further lines of therapy. Improved responses in brain metastases were observed for all second-and next/third-generation alk tyrosine kinase inhibitors in patients progressing on crizotinib. Canadian recommendations are therefore revised as follows: ■ Patients with advanced nonsquamous nsclc have to be tested for the presence of an ALK rearrangement. ■ Treatment-naïve patients with ALK-positive disease should initially be offered single-agent alectinib or ceritinib, or both sequentially. ■ Crizotinib-refractory patients should be treated with single-agent alectinib or ceritinib, or both sequentially. ■ Further treatments could include single-agent brigatinib or lorlatinib, or both sequentially. ■ Patients progressing on alk tyrosine kinase inhibitors should be considered for pemetrexed-based chemotherapy. ■ Other systemic therapies should be exhausted before immunotherapy is considered. Summary Multiple lines of alk inhibition are now recommended for patients with advanced nsclc with an ALK rearrangement.